Why does clinical practice vary between Doctors ?

Why does the United States spend so much on healthcare yet have such poor health outcomes? Why do many patients from the developing world believe that “injections” are a cure-all? The answer is simple: financial incentives are grossly disfiguring world healthcare. Pay doctors to intervene, and they duly will, irrespective of the harms caused. A nation’s health seeking behaviour is solely defined by the payment structure of its healthcare system. Thus, private systems have a vested interest in making us all patients, for this is just good business. More medicine should never be confused with better medicine. If we paid all doctors salaries, it would save money and lives and hence should be the number one health priority for the World Health Organization.

There is another unacknowledged, uninvestigated, yet irrefutable fact—that the personality of the doctor directly affects his or her clinical care and the advice he or she gives patients. And remember that clinical medicine is just a casino, playing the odds, counting cards, and working out the probability of disease. The good news is that the odds are wildly stacked in our favour, for disease is rare. Yet most doctors aren’t the gaming types, naturally uncomfortable with risk, unwilling to chance something going wrong, however long the odds. So, just as disease is declining, we are investigating ever more. The more tests, the more spurious abnormal results. We get a pyramid scheme, more referrals, more unnecessary investigation, an unstoppable chain reaction of false positive results. This is all compounded by superspecialism and the loss of generalism. We have forgotten the most important intervention of all—non-intervention. Little wonder that overdiagnosis, overtreatment, and iatrogenic harm are the defining characteristics of today’s financially unsustainable medicine.

And it’s not merely our personality that influences patient care but our own health beliefs as individual doctors. It is not science but emotion—beliefs in, for example, antibiotics for sore throats, physiotherapy, homeopathy, statins, acupuncture, pain, gluten, antidepressants, and the rest. This combination of personality and our disparate health beliefs explains the wide variance in referral rates (which vary 10-fold between GPs1), hospital admissions, prescribing rates, investigations, and, ultimately, the costs between doctors. None of this variance is explainable by epidemiology or the demographics of the populations served. This might even be worthy of research, but no one seems interested in the bigger picture when they have the microscopic to measure. So when patients often ask innocently, “What would you do if it were you, doctor?” the answer should come with a health warning.